The present invention relates to the use of sodium channel antagonists for the treatment of diseases mediated by, or exacerbated by, neuronal apoptosis, in particular sensory neuronal apoptosis.
EP-0021121-A discloses a group of 3,5-diamino-6-(substituted phenyl)-1,2,4-triazines which are active in the treatment of central nervous system (CNS) disorders, for example in the treatment of epilepsy. One such triazine is 3,5-diamino-6-(2,3-dichlorophenyl)-1,2,4-triazine which is alternatively called lamotrigine.
EP-0372934-A discloses pyrimidine compounds useful in the treatment of CNS disorders. Example 14 of this application discloses 5-(2,3-dichlorophenyl)-6-trifluoromethyl-2,4-diaminopyrimidine, Example 18 of EP-0372934-A discloses 2,4-diamino-5-(2,3-dichlorophenyl)-6-fluoromethyl pyrimidine and Example 45 discloses 5-(2,6-dichlorophenyl)-6-methyl-2,4-diaminopyrimidine.
WO 97/09317 discloses the R(xe2x88x92) enantiomer of Example 18 of EP0372934-A, R(xe2x88x92)-2,4-diamino-5-(2,3-dichlorophenyl)-6-fluoromethyl pyrimidine, substantially free of the corresponding S(+)enantiomer, ie the compound of formula (I): 
and acid addition salts thereof. This compound is also known as 4030W92.
WO98/38174 discloses pyrazine derivatives useful in the treatment of CNS disorders such as epilepsy, ie the compounds of formula (II): 
wherein
R1 is selected from the group consisting of phenyl substituted by one or more halogen atoms, naphthyl and naphthyl substituted by one or more halogen atoms;
R2 is selected from the group consisting of xe2x80x94NH2 and xe2x80x94NHC(xe2x95x90O)Ra;
R3 is selected from the group consisting of xe2x80x94NRbRc, xe2x80x94NHC(xe2x95x90O) Ra and hydrogen;
R4 is selected from the group consisting of hydrogen, xe2x80x94C1-4 alkyl (preferably methyl), xe2x80x94C1-4 alkyl (preferably methyl) substituted by one or more halogen atoms, xe2x80x94CN, xe2x80x94CH2OH, xe2x80x94CH2ORd and xe2x80x94CH2S(O)xRd;
xe2x80x83wherein
Ra represents C1-4 alkyl or C3-7cycloalkyl, and
Rb and Rc, which may be the same or different, are selected from hydrogen and C1-4 alkyl, or together with the nitrogen atom to which they are attached, form a 6-membered nitrogen containing heterocycle, which heterocycle can be further substituted with one or more C1-4 alkyl;
Rd is selected from C1-4 alkyl or C1-4 alkyl substituted by one or more halogen atoms;
x is an integer zero, one or two;
and pharmaceutically acceptable derivatives thereof;
with the proviso that R1 does not represent; 
when R2 is xe2x80x94NH2, and both R3 and R4 are hydrogen. Particularly preferred is 2,6-diamino-3-(2,3,5-trichlorophenyl)pyrazine and pharmaceutically acceptable derivatives thereof.
WO99/32462 (PCT/EP98/08273) relates to a triazine compound which is useful in the treatment of central nervous system (CNS) diseases and disorders, ie the compound 5-amino-6-[2,3,5-trichlorophenyl]-1,2,4-triazine and pharmaceutically acceptable derivatives thereof.
WO00/12488 relates to carboxamide derivatives of pyrazine compounds such as those disclosed in WO98/38174 above, in particular 5-carboxamido-2,6-diamino-3-(2,3,5-trichlorophenyl)pyrazine.
The compounds of EP-0021121-A, EP-0372934-A, WO 97/09317, WO98/38174 WO99/32462 and WO00/12488 are sodium channel antagonists and therefore inhibit glutamate release.
Other sodium ion channel blockers include local anaesthetics/anti-dysrhythmics such as: lidocaine, mexilitine, ropivacaine, levobupivacaine; anti-convulsants such as: oxcarbazepine, topiramate, rufinamide, Co-102862, NW-1015; anti-ischaemics such as: sipatrigine, BIIR-561, BIII-890 and RS100642 and the analgesics such as: RS132943, details for which are all available from public databases such as Pharmaprojects.
It has been shown that the sodium channel antagonist, lamotrigine can prevent motorneuronal apoptotic cell death after neonatal axotomy: Casanovas A. et al Neuroscience Vol.71 No2 pp313-325 1996.
This invention relates to a parallel finding of much greater medical significance, that as a result of their ability to prevent neuronal apoptosis, sodium channel antagonists have a disease modifying effect and serve to halt or delay (slow down) the progression of disease as opposed to merely treating the symptoms of disease. For example, in the case of chronic pain, the sodium channel antagonists are able to halt or delay the underlying process which is causing the pain as well as ease the pain as demonstrated by behavioural testing. Thereby sodium channel antagonists can alter disease states in particular pain states mediated by sensory neuronal apoptosis. The ability to halt or delay the progression of disease states such as certain pain states, neurodegenerative diseases and inflammation, provides a significant breakthrough in the management of these otherwise poorly treated conditions.
Diseases mediated by, or exacerbated by neuronal apoptosis in particular sensory neuronal apoptosis, include: pain states, such as chronic pain states, following nerve insult due to, for example, injury or infection ie pain states associated with tissue damage; neurodegenerative diseases such as multiple sclerosis and Parkinson""s disease; and inflammation. Sodium channel antagonists are of use in the treatment of these diseases and are also of use in delaying or halting the progression of these diseases.
It has previously been reported (see for example WO98/38186) that a deficiency of oxygen, for example in the region of a cerebral infarct, causes abnormally high concentrations of glutamic acid to be released. This leads to an overstimulation of excitatory amino acid receptors, eg NMDA receptors, resulting in the degeneration and death of neurones by way of a mechanism known as excitotoxicity. This process has been implicated in the pathophysiology of various neurodegenerative conditions. Sodium channel antagonists are known to inhibit glutamate release and therefore prevent the degeneration and death of neurones due to excitotoxicity.
However, neuronal apoptosis which occurs as a result of nerve damage is unrelated to nerve death due to excitotoxicity and it is not dependent on glutamic acid concentration. xe2x80x9cApoptosisxe2x80x9d is a form of programmed cell death. A report from the Cell Death Nomenclature Committee (Apoptosis, Necrosis or Oncosis, Levin S. Toxicological Sciences 41 155-156 1998) defines the prelethal steps that follow cellular injury as apoptosis or oncosis (but not necrosis). Apoptosis is characterised by cytoplasmic shrinkage and karyorrhexis (The Pathways of Cell Death: Oncosis, Apoptosis and Necrosis Trump B. F. et al Toxicological Pathology 25 (1) 82-88 (1997)xe2x80x94chromatin is fragmented and packaged in bits of cell membrane. This shows up as densely coloured apoptotic bodies when visualised using a nuclear stain under the light microscope. Using electron microscopy the cytosol appears dense, endoplasmic reticulum may be dilated and mitochondria are condensed. Blebs in the cytoplasm will typically contain organelles. Breaks in the DNA that lead to karyorrhexis can be identified using gel electrophoresis or TUNEL staining but this alone is no longer considered adequate as cells stained positive using TUNEL, do not necessarily have the characteristics of apoptosis when studied at the electron microscopy level. The fluorescent nuclear stain Hoechst 33342 and light microscopic analysis is now considered the best technique. The most striking gross morphological characteristic is cell shrinkage.
As mentioned above, agents which prevent neuronal apoptosis have a disease modifying effect and serve to halt or delay the progression of disease.
The invention accordingly provides, in a first aspect the use of sodium channel antagonists in the treatment of diseases mediated by, or exacerbated by, neuronal apoptosis.
In a further aspect, the invention provides the use of sodium channel antagonists as disease modifying agents in diseases mediated by, or exacerbated by, neuronal apoptosis.
There is also provided as a further aspect of the invention the use of sodium channel antagonists in the preparation of a medicament for the treatment of diseases mediated by, or exacerbated by, neuronal apoptosis.
The invention has particular relevance in the case of sensory neuronal apoptosis and disease mediated or exacerbated by sensory neuronal apoptosis.
In an alternative or further aspect there is provided a method for the treatment of a mammal, including man, suffering from or susceptible to neuronal apoptosis, comprising administration of an effective amount of a sodium channel antagonist.
In an alternative or further aspect there is provided a method for the treatment of a mammal, including man, suffering from or susceptible to diseases mediated by, or exacerbated by, neuronal apoptosis, comprising administration of an effective amount of a sodium channel antagonist.
In a further aspect the invention provides the use of sodium channel antagonists in delaying or halting the progression of diseases selected from pain states following nerve insult, neurodegenerative diseases such as multiple sclerosis and Parkinson""s, and inflammation.
In a further aspect the invention provides the use of sodium channel antagonists in the treatment of multiple sclerosis and inflammation.
It will be appreciated that reference to treatment is intended to include prophylaxis as well as the alleviation of established symptoms.
Preferred sodium channel antagonists for use in the instant invention include those compounds included in EP-0021121-A, EP-0372934-A, WO 97/09317, WO98/38174, WO99/32462 and WO00/12488, especially:
i) 3,5-diamino-6-(2,3-dichlorophenyl)-1,2,4-triazine called lamotrigine;
ii) R(xe2x88x92) and S(+)-2,4-diamino-5-(2,3-dichlorophenyl)-6-fluoromethylpyrimidine, called 4030W92 and 4082W92 respectively;
iii) 2,6-diamino-3-(2,3,5-trichlorophenyl)pyrazine;
iv) 5-amino-6-[2,3,5-trichlorophenyl]-1,2,4-triazine and pharmaceutically acceptable derivatives thereof;
v) (+/xe2x88x92)5-(2,3-dichlorophenyl)-6-trifluoromethyl-2,4-diaminopyrimidine and
vi) (+/xe2x88x92)5-(2,6-dichlorophenyl)-6-methyl-2,4-diaminopyrimidine and their enantiomeric forms;
vii) 5-carboxamido-2,6-diamino-3-(2,3,5-trichlorophenyl)pyrazine.
Particularly preferred is R(xe2x88x92)-2,4-diamino-5-(2,3-dichlorophenyl)-6-fluoromethyl pyrimidine, substantially free of the corresponding S(+)enantiomer.
Sodium channel antagonists may be prepared according to methods known in the art, for example according to the methods described in EP-0021121-A, EP-0372934-A, WO 97/09317, WO98/38174, WO99/32462 and WO00/12488.
5-Amino-6-[2,3,5-trichlorophenyl]-1,2,4-triazine may be prepared under suitable reaction conditions from a compound of formula (IIa) 
for example, by reduction, preferably using a reduction metal, such as Raney nickel, and a source of hydrogen, such as hydrazine monohydrate, in a suitable solvent, such as ethanol, preferably at elevated temperature, for example between 70-75xc2x0 C.
The compound of formula (IIa) may suitably be prepared by reacting 2,3,5-trichlorobenzoyl cyanide with a S-methylthiosemicarbazide salt, preferably hydroiodide, in the presence of a dilute mineral acid, preferably dilute sulphuric acid.
Other sodium ion channel blockers for use in the invention include compounds such as: lidocaine, mexilitine, ropivacaine, levobupivacaine; compounds such as: oxcarbazepine, topiramate, rufinamide, Co-102862, NW-1015; compounds such as: sipatrigine and BIIR-561, BIII-890 and RS100642; and compounds such as RS132943, details for which are all available from public databases such as Pharmaprojects.
Suitable dose ranges are as described in the art, eg as in EP-0021121-A, EP-0372934-A, WO 97/09317, WO98/38174, WO99/32462 and WO00/12488. That is to say that for use according to the present invention the sodium channel antagonists may be used at doses appropriate for other conditions for which they are known to be useful. It will be appreciated that it may be necessary to make routine variations to the dosage, depending on the age and condition of the patient, and the precise dosage will be ultimately at the discretion of the attendant physician or veterinarian. The dosage will also depend on the route of administration and the particular compound selected. A suitable dose range is for example 0.1 mg/kg to 30 mg/kg bodyweight per day calculated as the free base, for example 3 mg/kg to 15 mg/kg. A suitable dose for an adult human is for example in the range of 200 mg to 900 mg per day.
The sodium channel antagonists may, if desired, be administered in combination with one or more other therapeutic agents and formulated for administration by any convenient route in a conventional manner. Appropriate doses will be readily appreciated by those skilled in the art.
FIG. 1. Numbers of neurones undergoing apoptosis in the naive animal and at three time points after CCI surgery (7,21 and 30 days). Neuronal apoptosis is elevated up to 30 days post surgery.
FIG. 2. The number of neurones undergoing apoptosis decreases when CCI animals (n=3 day 7, n=2 day 21, n=3 day 30) are treated with the sodium channel blocker 4030W92 10 mgKgxe2x88x921 (crossed bars) and 4082W92 10 mgkgxe2x88x921 (slanted bars) (numbers per group as for vehicle timepoints). Levels in the vehicle treated animals (solid bars) remained constant over the time course. In CCI animals at all time points there were significantly more apoptotic cells than in naive animals (n=4) (hollow bar).